Provider Demographics
NPI:1215543251
Name:PUGH, KENYATTA
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:PUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1176 VICKERY LN STE 200
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0631
Mailing Address - Country:US
Mailing Address - Phone:901-255-4490
Mailing Address - Fax:901-416-4490
Practice Address - Street 1:1176 VICKERY LN STE 200
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0631
Practice Address - Country:US
Practice Address - Phone:901-255-4490
Practice Address - Fax:901-416-4490
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN170003871374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide